Short-term survival in extensive craniofacial resections

OBJECTIVES: Craniofacial resection (CFR) procedures for craniofacial tumors with cranial extension are often extensive. Although CFRs may yield good oncological results, there are concerns about high perioperative morbidity and mortality. This study aimed to determine risk factors for perioperative mortality after open CFR in terms of deaths occurring during index hospitalizations. METHODS: We conducted a retrospective analysis of CFRs conducted at a tertiary oncology hospital from May 2009 through December 2018. RESULTS: Our analysis included data from the medical records of 102 patients, the majority of whom were male (n=74, 72.5%). The mean age was 61 years (±18.3 years). Skin malignancies (n=64, 63.4%) accounted for nearly two-thirds of the treated tumors, and most of these were squamous cell carcinoma. Postoperative medical complications occurred in 33 patients (33%), and surgical complications occurred in 48 (47%). Multivariate analysis revealed the only independent risk factors for perioperative deaths to be the presence of intracranial tumor extension on preoperative imaging (hazard ratio [HR]=4.56; 95% confidence interval [CI]: 1.74-11.97; p=0.002) and the unexpected emergence of postoperative neurological dysfunction (HR=10.9; 95% CI: 2.21-54.3; p=0.003). CONCLUSIONS: In our study, factors related to tumor extension were associated with a higher risk of perioperative death.

Supratracheal laryngectomy: a multi-institutional study / Laringectomia supratraqueal: um estudo multi-institucional

Abstract Introduction: Supratracheal laryngectomy has been described as a surgical procedure for glottic or supraglottic cancer extending to the subglottic region and/or involving the cricoarytenoid joint, aiming to preserve laryngeal function (breathing, phonation and swallowing), without diminishing locoregional cancer control. The choice of supracricoid laryngectomy in these cases could result in a high risk of compromised resection margins. Objective: To determine the safety, viability, adequacy of surgical margins and the supratracheal laryngectomy results for intermediate and advanced laryngeal cancer by reviewing the results at three different institutions in Brazil. Methods: This is a retrospective study that analyzed the charts of 29 patients submitted to supratracheal laryngectomy from October 1997 to June 2017. The type of laryngectomy performed was classified according to the European Laryngological Society classification for horizontal laryngectomies. Early and late results were evaluated. Survival rates (overall, specific, disease-free and total laryngectomy-free survival) were calculated. The mean follow-up time was 44 months. Results: Of the 29 patients submitted to supratracheal laryngectomy, 25 had no previous treatment. One patient (3.4%) had compromised margins. Four patients (13.8%) had recurrence. Of these, three had local recurrence and one had regional recurrence. Five patients (17.2%) required a total laryngectomy, two due to ruptured pexy and three due to local recurrence. Four of these patients (80%) achieved a successful total procedure. Four patients (13.8%) died, two due to postoperative complications and two due to recurrence. Overall, specific, disease-free and total laryngectomy-free survival at 5 years were, respectively, 82.1%; 88.2%; 83.0% and 80.2%. Conclusion: Selected patients with intermediate and advanced laryngeal cancer may benefit from supratracheal laryngectomy, that resulted in total laryngectomy-free survival and specific survival of 80.2% and 88.2%, respectively.

Resumo Introdução: A laringectomia supratraqueal tem sido descrita como um procedimento cirúrgico com objetivo de preservar a função da laringe (respiração, fonação e deglutição), sem prejuízo no controle oncológico locorregional, para câncer glótico ou supraglótico com extensão à subglote e/ou envolvimento da articulação cricoaritenóidea. A opção pela laringectomia supracricoide nesses casos poderia resultar em grande risco para margens de ressecção comprometidas. Objetivo: Determinar a segurança, viabilidade, adequação das margens cirúrgicas e os resultados da laringectomia supratraqueal para o câncer de laringe intermediário e avançado através da revisão dos resultados de três instituições distintas no Brasil. Método: Estudo retrospectivo, com análise dos prontuários de 29 pacientes submetidos à laringectomia supratraqueal, de outubro de 1997 a junho de 2017. O tipo de laringectomia realizada foi classificado de acordo com a classificação da Sociedade Laringológica Europeia para laringectomias horizontais. Foram avaliados os resultados precoces e tardios. As taxas de sobrevida (global, específica, livre de doença e livre de laringectomia total) foram calculadas. O tempo médio de seguimento foi 44 meses. Resultados: Dos 29 pacientes submetidos à laringectomia supratraqueal, 25 não tinham tratamento prévio. Um paciente (3,4%) teve margens comprometidas. Quatro pacientes (13,8%) recidivaram. Desses, três tiveram recidiva local e um apresentou recidiva regional. Cinco pacientes (17,2%) necessitaram de totalização da laringectomia, duas por ruptura da pexia e três por recidiva local. Quatro desses pacientes (80%) obtiveram sucesso na totalização. Quatro pacientes (13,8%) foram a óbito, dois por complicações pós-cirúrgicas e dois por recidiva. As sobrevidas global, específica, livre de doença e livre de laringectomia total em 5 anos foram, respectivamente, 82,1%; 88,2%; 83,0% e 80,2%. Conclusão: Pacientes selecionados com câncer intermediário e avançado de laringe podem ser beneficiados com laringectomia supratraqueal, que ofereceu sobrevida livre de laringectomia total e sobrevida específica de 80,2% e 88,2%, respectivamente.

Invasión ósea del carcinoma de células escamosas de la cavidad oral, análisis clínico - patológico de 62 casos / Bone invasion of squamous cell carcinoma of the oral cavity, clinical-pathological analysis of 62 cases

RESUMEN Introducción: El pronóstico de pacientes con carcinoma de células escamosas (CEC) de la cavidad oral con presencia de invasión ósea continua sombrío. El patrón de invasión ósea puede ser usado como indicador de agresividad y correlacionado con el comportamiento clínico del tumor. Objetivo: Evaluar los patrones histopatológicos de invasión ósea en pacientes con CEC de la cavidad oral y correlacionarlos con la tasa de sobrevida. Materiales y métodos: La muestra fue constituida por 62 pacientes con presencia de CEC en la cavidad oral e invasión ósea. Las características epidemiológicas e histopatológicas fueron tabuladas y analizadas. Los Test Chi- cuadrado y exacto de Fischer fueron empleados para verificar las asociaciones estadísticas entre los datos. Resultados: Fueron afectados más hombres en la quinta década de vida y observada una fuerte asociación con tabaquismo y etilismo crónico. Fueron relatadas muertes en 58% de los pacientes, en un periodo de 5 años. El patrón histológico más prevalente fue el infiltrativo, asociado a menores tasas de sobrevida. Conclusión: El análisis del patrón histopatológico de los CEC de la cavidad oral, puede ser usado como factor pronóstico auxiliando en la decisión del abordaje del tratamiento oncológico.

SUMMARY Introduction: Prognosis for patients with squamous cell carcinoma (SCC) in oral cavity with bone invasion presence is concerning. Bone invasion patterns can be used to indicate aggressiveness and can be correlated with tumor clinical behavior. Objective: To evaluate bone invasion histopathological patterns in patients with oral cavity SCC and correlate them with the survival rate. Materials and methods: 62 patients with presence of SCC in the oral cavity as well as bone invasion were recruited for this study. Epidemiological and histopathological characteristics were tabulated and analyzed. Fischer's Square and Exact Tests were used to verify any statistical associations between the data. Results: More men were affected, especially in the fifth decade of life, and a strong association with smoking and chronic alcoholism was observed. Deaths were reported in 58% of patients, over a period of 5 years. The most prevalent histological pattern was the infiltrative, associated with lower survival rates. Conclusion: An analysis of the histopathological patterns of oral cavity SCC can be used as a prognostic factor thereby assisting with the decision of which oncological treatment approach to use.

Evaluation of lung function in patients submitted to total laryngectomy / Avaliação da função pulmonar em pacientes submetidos à laringectomia total

Abstract Introduction: The post-laryngectomy state is characterized by several alterations in lung function. A reliable estimation of lung function can be very useful in laryngectomees to prevent postoperative complications and to evaluate the results of the treatment. Objective: Characterize the presence of respiratory functional disorders and the functional pattern of laryngectomees through the use of an extratracheal device. Methods: This transversal study included 50 patients submitted to total laryngectomy at least 6 months prior to this investigation, as the treatment of choice for laryngeal cancer. Results: 56% percent of the participants had altered breathing pattern, distributed as follows: 14 with obstructive pattern with no air trapping, 11 with obstructive pattern with air trapping and only 3 with restrictive pattern. On average, the diffusion decreased (74.3%) and airway resistance increased (121.7%) when compared to the expected average values for the Brazilian individuals. Conclusion: Most patients submitted to total laryngectomy present altered lung function, usually the obstructive type, frequently associated to a history of smoking.

Resumo Introdução: A condição pós-laringectomia é caracterizada por várias alterações na função pulmonar. Uma estimativa confiável da função pulmonar pode ser muito útil em pacientes laringectomizados para prevenir complicações após as intervenções cirúrgicas e avaliar os resultados do tratamento. Objetivo: Caracterizar a presença de distúrbios funcionais respiratórios e o padrão funcional de pacientes laringectomizados através do uso de um dispositivo extratraqueal. Método: Estudo transversal que incluiu 50 pacientes submetidos à laringectomia total pelo menos seis meses antes desta investigação, como tratamento de escolha para o câncer de laringe. Resultados: Dos participantes, 56% apresentavam padrão respiratório alterado, assim distribuídos: 14 com padrão obstrutivo sem aprisionamento aéreo, 11 com padrão obstrutivo e aprisionamento aéreo e apenas três com padrão restritivo. Em média, verificou-se que a difusão encontrava-se diminuída (74,3%) e a resistência das vias aéreas aumentada (121,7%) em relação aos resultados esperados em brasileiros. Conclusão: A maioria dos pacientes submetidos à laringectomia total apresenta função pulmonar alterada, do tipo obstrutiva, quase sempre associada a história de tabagismo.

Surgical treatment for thyroid carcinoma: retrospective study with 811 patients in a Brazilian tertiary hospital

ABSTRACT Objective The aim of the present study was to describe the epidemiologic data, histological type, treatment and follow-up of the 811 patients treated for thyroid cancer in Instituto do Câncer do Estado de São Paulo (ICESP) over 5 years. Materials and methods Retrospective analyses of electronic chart information. Results There were 679 cases (83.7%) of papillary thyroid cancer, 61 (7.5%) of follicular carcinoma, 54 (6.7%) of medullary carcinoma, 11 (1.4%) of poorly differentiated carcinoma and 6 of anaplastic carcinoma (0.7%). The majority of patients were female (82.2%), and the mean age was 50.5 ± 15 years. Two hundred forty-two patients had disease persistence or recurrence. At the last follow-up, 629 (77.6%) patients were alive and disease free, 141 (17.4%) were alive with disease, and 41 (5.1%) were deceased, with 37 deaths related to thyroid cancer. Conclusion This study was able to outline the profile, disease type and evolution of patients treated for thyroid cancer at a single tertiary hospital.

Surgical approach to medullary thyroid carcinoma associated with multiple endocrine neoplasia type 2

We briefly review the surgical approaches to medullary thyroid carcinoma associated with multiple endocrine neoplasia type 2 (medullary thyroid carcinoma/multiple endocrine neoplasia type 2). The recommended surgical approaches are usually based on the age of the affected carrier/patient, tumor staging and the specific rearranged during transfection codon mutation. We have focused mainly on young children with no apparent disease who are carrying a germline rearranged during transfection mutation. Successful management of medullary thyroid carcinoma in these cases depends on early diagnosis and treatment. Total thyroidectomy should be performed before 6 months of age in infants carrying the rearranged during transfection 918 codon mutation, by the age of 3 years in rearranged during transfection 634 mutation carriers, at 5 years of age in carriers with level 3 risk rearranged during transfection mutations, and by the age of 10 years in level 4 risk rearranged during transfection mutations. Patients with thyroid tumor >5 mm detected by ultrasound, and basal calcitonin levels >40 pg/ml, frequently have cervical and upper mediastinal lymph node metastasis. In the latter patients, total thyroidectomy should be complemented by extensive lymph node dissection. Also, we briefly review our data from a large familial medullary thyroid carcinoma genealogy harboring a germline rearranged during transfection Cys620Arg mutation. All 14 screened carriers of the rearranged during transfection Cys620Arg mutation who underwent total thyroidectomy before the age of 12 years presented persistently undetectable serum levels of calcitonin (<2 pg/ml) during the follow-up period of 2-6 years. Although it is recommended that preventive total thyroidectomy in rearranged during transfection codon 620 mutation carriers is performed before the age of 5 years, in this particular family the surgical intervention performed before the age of 12 years led to an apparent biochemical cure.

Estudo da anatomia do ramo mandibular do nervo facial / Anatomic study of the mandibular ramus of the facial nerve

O ramo mandibular do nervo facial inerva os músculos depressor da rima bucal e depressor do lábio inferior. Procedimentos que abordam a regiao submandibular podem lesá-lo, o que leva ao desvio da rima labial e conseqüente deformaçao da estética facial. Neste estudo foram analisados quarenta ramos mandibulares do nervo facial em vinte cadáveres dissecados, demonstrando sua freqüente representaçao por mais de um ramo, a presença de anastomoses com outros ramos e sua distância de até treze milímetros da borda inferior da mandíbula.

Limites das ressecçöes craniofaciais oncológicas / Limits of oncological craniofacial resections

A cirurgia oncológica da base do crânio vem sendo utilizada desde a década de 1940. Um número muito grande de publicaçoes serviu para difundir o seu uso nos anos seguintes. Contudo, muito pouco se tem publicado sobre as indicaçoes desses grandes procedimentos operatórios e, principalmente, sobre as suas limitaçoes. Houve uma sensível expansao destes limites, principalmente a partir da década de 1980. Há, porém, situaçoes que exigem uma análise muito cuidadosa da indicaçao cirúrgica e podem, por vezes, contra-indicá-la. Por razoes didáticas, os limites podem ser divididos em: intracranianos, faciais e "filosóficos". Podem representar limites intracranianos: invasao de duramáter, do parênquima cerebral, da artéria carótida interna, do seio cavernoso ou dos nervos cranianos. A impossibilidade de se utilizar a microcirurgia reconstrutiva e a invasao orbitária bilateral se incluem entre os limites faciais. Finalmente, podem serdenominados limites "filosóficos" a indicaçao destes procedimentos para tumores benignos ou para lesoes malianas de tipos histológicos muito agressivos ou disseminadas. Na experiência da Disciplina de Cirurgia de Cabeça e Pescoço do Hospital das Clínicas da FMUSP, alguns fatores de pior prognostico, que permitiram delinear alguns destes limites foram: tipos histológicos de maior malignidade, tumores recidivados e necessidade de reconstruçao microcirúrgica.

Analise retrospectiva de 100 parotidectomias / Parotidectomy: retrospective analysis of 100 cases

Sao analisados diferentes aspectos de 100 pacientes submetidos a parotidectomias, consecutivas, no periodo de janeiro de 1981 a janeiro de 1989. Os resultados sao comparados e discutidos,com base na literatura consultada, sobre tumores de parotida e parotidectomias. Foram realizadas 72 parotidectomias superficiasis e 18 parotidectomias totais, com achado de 69% de neoplasias benignas, 17% de neoplasias malignas, 4% de sialoadenite cronica e 10% de tumores nao parotideos. A incidencia de tumores do lobo profundo da glandula foi de 17%. Observamos, no pos-operatorio, deficit motor-temporario no territorio do nervo facial em 34% dos pacientes. A recidiva, com acompanhamento de cinco anos em media, foi de 3%. Nosso estudo apresenta certas peculiaridades, mas e, em geral, similar aos encontrados na literatura, quando comparadas as estatisticas

Reconstruçäo craniofacial microcirúrgica / Microsurgical cranofacial reconstruction

De 1981 a 1988, 10 pacientes portadores de extensas lesöes tumorais em Cabeça e Pescoço foram submetidos a ressecçöes craniofaciais oncológicas, seguidos de reconstruçäo com retalhos transplantados com microcirurgia vascular. Foram executados 11 retalhos microcirúrgicos: cinco do músculo grande dorsal, três do músculo reto abdominal, um do omento maior e um paraescapular. Bons resultados foram obtidos em nove pacientes (90%) e nove retalhos (82%). Num mesmo doente, houve perda total dos dois retalhos microcirúrgicos empregados (um grande dorsal e um omento maior), provavelmente devido a uma somatória de fatores desfavoráveis. Após a apresentaçäo detalhada de um caso representativo e da análise crítica, algumas conclusöes säo delineadas em relaçäo a estas técnicas reconstrutivas